Archived: Dr R Suntharalingam

Updated 9 July 2015

Dr Suntharalingam is located in a purpose built health centre. The property is owned by NHS property Service which is responsible for the maintenance of the building. It is situated in the heart of Tilbury, with parking facilities at the front and rear of the premises, whilst also benefiting from having access to public transport, being on a main bus route. They accept patients from within a three mile radius of the RM18 postcode area.

The practice holds a General Medical Service contract. This is the type of contract the practice holds with NHS England to provide medical care to patients. It has 2,222 patients registered with the practice. The practice is open from 8:30am to 6:30pm on Monday, Tuesday and Friday and, 8:00am to 6:30pm on a Wednesday and 8:30am to 1pm on a Thursday. Appointments are available from 9:30am to 11:30am and 4pm to 6pm on Monday, Tuesday, Wednesday and Friday. The practice closes half day on Thursday afternoon with appointments available from 09:30am to 1pm. The telephone messages then divert patients to the out of hours service if they require medical assistance or the national health advice 111 service. Telephone consultations are also offered to patients unable to attend the practice or wishing to receive an urgent appointment on the day. The practice is run by a single GP practitioner, a male, and two practice nurses who combined work one and a half days a week. The practice is supported by a small administrative/reception team.

The practice population is slightly younger than the national average with higher representation amongst the under 18 age group. Their patient deprivation levels for both children and older people were significantly higher than the practice average across England. Life expectancy for men was 79 and the women a year younger than the average at 82 years of age. Their patients had higher than average long standing health conditions and had a lightly higher than national average for disability allowance claimants.

The practice maintains a comprehensive website detailing practice opening and consultation times, information relating to their Virtual Patient Participation Group, guidance on health issues such as childhood aliments, what to do in an emergency and preparing for pregnancy.

The practice has opted out of providing out-of-hours services to their own patients. The services are provides by SEEDS which is the South East Essex Emergency Doctors Service. Information is provided to patients about the out of hours provision and patients are actively encouraged to call them prior to attending accident and emergency services.

Updated 9 July 2015

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Suntharalingam on 6 May 2015. Overall the practice is rated as inadequate.

Specifically, we found the practice to require improvement for providing caring services. It was inadequate for providing safe, effective, responsive and well led service and therefore inadequate for providing services to the older people, people with long-term conditions, families, children and young people, working age people (including those recently retired and students), people living in vulnerable circumstances, and people experiencing poor mental health (including people with dementia).

Our key findings across all the areas we inspected were as follows:

• Patients were at risk of harm because systems and processes were not in place to keep them safe. For example appropriate recruitment checks on staff had not been undertaken prior to their employment and infection prevention control risks had not been identified and there were no records maintained to demonstrate cleaning had been conducted.
• Staff had not received training and development and there were no systems to assess staff competence to conduct their clinical roles and responsibilities.
• There were insufficient systems and processes in place to ensure medicines were in date and suitable for use.
• The lead GP and staff were not clear about reporting incidents, near misses and concerns. Where significant incidents had occurred such as the theft of the GP’s medical bag containing medicines from an insecure vehicle. It had not been reported to the police or lessons learnt to mitigate the potential of the incident happening again. There were no records of investigations being conducted or learning and communication with staff.
• There was insufficient assurance to demonstrate people received effective care and treatment. For example, there was an absence of systems in place to ensure patients’ clinical needs were reviewed in a timely and appropriately manner such as in response to changes in medication and reviewing patients with one or more long term condition. We found patients had new medications added to their prescriptions without prior discussion with them.
• Patients were positive about their interactions with staff and said they were treated with compassion and dignity.
• Urgent appointments were usually available on the day they were requested. However patients said that they sometimes had to wait a long time for non-urgent appointments and that the nurse’s appointments were often booked or cancelled at short notice.
• The practice had a clear leadership structure, but insufficient awareness and an absence of formal governance arrangements to ensure the safe and effective delivery of care. For example, staff told us no records of meetings were maintained or available to us when we asked the practice manager. The GP failed to take responsibility for ensuring the safe and appropriate appointment and supervision of clinical staff.

The areas where the provider must make improvements are:

• Ensure systems and processes are in place to ensure a clean and safe environment for patients.
• Ensure recruitment arrangements include all necessary employment checks for all staff.
• Put systems in place to ensure all clinicians are kept up to date with national guidance and guidelines.
• Ensure suitable arrangements are in place to ensure equipment is safe and suitable for use
• Ensure there are formal governance arrangements in place including systems for assessing and monitoring risks and the quality of the service provision e.g. medicines are in date and suitable for use.
• Ensure staff have appropriate policies and guidance to carry out their roles in a safe and effective manner which are reflective of the requirements of the practice.
• Ensure there is leadership capacity to deliver all improvements

The areas where the provider should make improvement are:

• Staff should be risk assessed to ascertain if a criminal records check through the Disclosure and Barring Service are required.
• Legionella risk assessments should be undertaken
• The practice should maintain accurate records for meetings.

On the basis of the ratings given to this practice at this inspection, I am placing the provider into special measures. This will be for a period of six months. We will inspect the practice again in six months to consider whether sufficient improvements have been made. If we find that the provider is still providing inadequate care we will take steps to cancel its registration with CQC.

I have also served a notice on the provider placing conditions on their registration, which they must comply with. The conditions are that the practice must close their patient register, therefore, new patients are not permitted to register with the practice for a period of six months.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 9 July 2015

The provider was rated as requires improvement for caring overall and this includes this population group. The provider was rated as inadequate for safety, effective, responsive and well led. The concerns which led to these ratings apply to everyone using the practice, including this population group.

The practice is rated as inadequate for the care of people with long-term conditions. Longer appointments were available on request as were home visits. All patients had a named GP however there were no personalised care plans in place. Information was not appropriately shared with the out of hours provider so as to ensure safe and coordinated care outside of normal working hours. Structured annual reviews and health checks were not undertaken to check that patients’ health and care needs were being met.

Updated 9 July 2015

The provider was rated as requires improvement for caring overall and this includes this population group. The provider was rated as inadequate for safety, effective, responsive and well led. The concerns which led to these ratings apply to everyone using the practice, including this population group.

The practice is rated as inadequate for the care of families, children and young people. There were no systems to identify and follow up patients in this population group who were living in disadvantaged circumstances and who were at risk. Staff had not received training in safeguarding contrary to the practice policy and were unaware of the escalation procedures should they have concerns. There was inconsistent availability of nursing staff to deliver the practice immunisations programme and legal requirements for the safe and appropriate administration of vaccinations had not been met.

Updated 9 July 2015

The provider was rated as requires improvement for caring overall and this includes this population group. The provider was rated as inadequate for safety, effective, responsive and well led. The concerns which led to these ratings apply to everyone using the practice, including this population group.

The practice is rated as inadequate for the care of older people. The safety of care for older people was not a priority and there were no attempts at measuring safe practice. We saw evidence which showed that basic care and treatment requirements were not met such as scheduling reviews and developing care plans for patients. The care of older people was not managed in a holistic way. The leadership of the practice had little understanding of the needs of older people and was not attempting to improve the service for them. Services for older people were therefore reactive, and there was a no evidence of an attempt to engage this patient group to improve the service.

Updated 9 July 2015

The provider was rated as requires improvement for caring overall and this includes this population group. The provider was rated as inadequate for safety, effective, responsive and well led. The concerns which led to these ratings apply to everyone using the practice, including this population group.

The practice is rated as inadequate for the care of working-age people (including those recently retired and students). The age profile of patients at the practice is mainly those of working age or young children and people the services available did not reflect the needs of this group. Appointments could only be booked by telephone and in person. There was limited availability with the practice nurses who worked one and a half days a week in total. The practice offered extended opening hours four days a week for working people. The practice was did not monitor its uptake of either health checks and health screening as part of reviewing patient care and promoting good health.

Updated 9 July 2015

The provider was rated as requires improvement for caring overall and this includes this population group. The provider was rated as inadequate for safety, effective, responsive and well led. The concerns which led to these ratings apply to everyone using the practice, including this population group.

The practice is rated as inadequate for the care of people experiencing poor mental health (including people with dementia). The practice was unable to identify patients experiencing poor mental health or those with dementia. It had not worked with multi-disciplinary teams in the case management of people experiencing poor mental health. It did not carry out advance care planning for patients with dementia.

The practice had not told patients experiencing poor mental health about support groups or voluntary organisations. It did not have a system in place to identify to follow up patients who had attended accident and emergency (A&E) where they may have been experiencing poor mental health.

Updated 9 July 2015

The provider was rated as requires improvement for caring overall and this includes this population group. The provider was rated as inadequate for safety, effective, responsive and well led. The concerns which led to these ratings apply to everyone using the practice, including this population group.

The practice is rated as inadequate for the care of people whose circumstances may make them vulnerable. The practice did not hold a register of patients living vulnerable circumstances. It was unable to identify which patients were potentially vulnerable and could not demonstrate that these patients received their annual health check.

The practice had not worked with multi-disciplinary teams in the case management of vulnerable people. Some staff told us they knew how to recognise signs of abuse in vulnerable adults and children. However they had not received training and were not aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies out of normal working hours.